APTA Meets With CMS for Clarification on New Medical Manual Review Process

Tuesday, April 02, 2013

APTA Meets With CMS for Clarification on New Medical Manual Review Process

Yesterday,
APTA along with other therapy stakeholder organizations met with the Centers
for Medicare and Medicaid Services (CMS) to discuss implementation of the
manual medical review (MMR) process for outpatient therapy claims exceeding
$3,700. As reported March 22 in News Now, recovery audit
contractors (RACs) will complete 2 types of review for claims processed on or
after April 1, 2013—prepayment review for states within the Recovery Audit
Prepayment Review Demonstration, and immediate postpayment review for the
remaining states.

CMS
assured stakeholders that the agency would have the necessary safeguards in
place to ensure appropriate and fair medical review by RACs. Prior to the
meeting, the therapy organizations sent a detailed list of questions to CMS
regarding the use of the advanced beneficiary notice (ABN), RAC administration,
and outreach education to Medicare contractors, providers, and patients. CMS
indicated that it plans to issue a written FAQ of the questions submitted in
the coming weeks.

During
the meeting, CMS clarified the following:

When claims exceed the $3,700 threshold in the
states under postpayment review, the claim will be paid automatically, and
providers will receive an additional development request (ADR) from the
Medicare administrative contractor (MAC). The provider should send the ADR
directly to the RAC. If the ADR is sent to the MAC, the MAC will forward
it to the RAC for review, which will slow down the review process as the
10-day clock does not begin until the RAC receives the ADR.

The RAC will not automatically deny coverage if
an ADR is not received; it will reach out to the provider to request the
information.

After the RAC reviews the ADR, it will send the
provider a detailed review letter either stating there is no finding of
error or denying the claim. This letter will be sent by US mail, but all
payments and adjustment of payments will be made electronically.

Providers will be able to track claims
submitted to the RAC through a claims status portal, and provider
submission requests will still be sent via mail or fax (the provider can
also send a DVD or CD to the RAC). Providers who are enrolled in
Medicare's ESMD system can submit claims electronically.

If the provider is has more than 1 therapy
clinic, the MMR will be completed by the RAC with jurisdiction over the
region in which the provider's practice is headquartered. RACs will look
only at claims above the $3,700 threshold, and claims will be reviewed on
a claim-by-claim basis and will not be bundled (first claim in, first
claim out).

Providers should use the ABN in the same manner
for claims above and below the therapy cap. This means that ABNs should be
issued only for services that the provider believes are not medically
necessary and coverage will be denied. If the patient refuses to sign an
ABN, the provider has no obligation to provide therapy that he or she believes
will be denied for lack of medical necessity.

In
the coming days, APTA will provide additional resources to members on the application
of the 2013 MMR process. Resources and the latest information on the therapy
cap can be found on APTA's 2013 Medicare Changes webpage.